Every finding on record at Brighton Hospice Wisconsin

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 16 (6%) clinical records reviewed for patients that accepted hospice aide services, it was revealed that the agency did not ensure the clinical notes for hospice aide services provided were documented in accordance to agency policy. Agency policy #1-027, Missed Visits (Dated 06/2022), stated in part, "Policy: Missed visits will be communicated to the interdisciplinary group at the IDG meeting. Procedure: 2. If a visit is missed and not rescheduled, the clinician will: A. Notify the IDG and the clinical supervisor of the missed visit and the reason for the missed visit. B. Document in the patient clinical record the following information: 1. Patient name; 2. Date and type of visit that was missed; 3. Reason for the missed visit.” CLINICAL RECORD 14: The aide care plan, dated 06/07/2025, ordered an aide frequency of "5 times a week for 8 weeks.” For the week of 07/13/2025, the record included evidence of three (3) completed aide visits on 07/14/2025, 07/16/2025, 07/17/2025, and two (2) "missed visits" notes dated 07/15/2025 and 07/18/2025, neither of which included the reason for the missed visit. The RN was informed of the missed visits however the IDG meeting notes dated 07/22/2025 recorded "Missed visits: None.” The clinical notes lacked documented evidence that the IDG was notified of the missed visits and they did not include the reason why the aide visits were missed, per agency policy. During an interview on 08/06/2025, the Coordinator of Aide Services said that the EMR (electronic medical record) did not have an area where the reason for the missed visit could be documented. They said they were upset the reason for these was not documented and stated, "There was a new "missed visit" process that started on 07/01/2025 to ensure the aide missed visits, with the reason, are being reported and documented at the IDG meetings.” During interview on 08/06/2025 while performing joint clinical record review, the Senior Director of Clinical Quality confirmed the clinical record notes did not include documentation as to the reason for the missed aide visits or notification of the IDG team of the "missed visits.”